I am registering for:
Sprouts Academy
Food Production Program
The Grind Leadership Program
Child Name
*
First Name
Last Name
Birthdate
Ethnicity
Gender
T-Shirt Size
Parent/Guardian's Name
First Name
Last Name
Email Address
*
Cell Phone
*
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact Name
*
Emergency Contact Phone
*
(###)
###
####
Additional Information
PLEASE PROVIDE any additional information about your child that you think is important or that may affect the child’s ability to fully participate in the summer camp program/youth program. Attach additional information if needed.
Agreement
*
I, as the of Participant, Parent/Legal Guardian of Minor Participant, Do herby indemnify, save, defend, hold harmless, release, and forever discharge UEmpower of Maryland, it’s employees, instructors and volunteers, from any and all, present and future liability, demands, suits, actions, or claims for losses, damages, or injury, including death, sustained by the participant arising from the participant’s participation in any related city programs, activities, trips, and excursions, regardless of whether such claims, losses, damages or injuries result, in whole or part, from the negligence of the of UEmpower of Maryland, it’s employees, instructors and volunteers. This provision shall survive termination of this release and authorization.
I have read and fully understand the above waiver and release of all claims. If registering on-line or via fax, my on-line or facsimile signature shall substitute for and have the same legal effect as an original form signature.
By checking the box below, I as the Participant or Parent / Legal Guardian of the Participant, acknowledge and agree to the above.
Health Info
The parent/guardian’s responsibility is to supply medication and fill out authorization forms for administration.
Below please check any medical conditions that may require attention during program time.
*
Do you have any dietary restrictions or specific dietary needs that we should be aware of for your child?
If yes, please provide details:
Myself/My child:
Allergy Info
*
By checking below, I/we acknowledge the following facts, and that prior to enrolling my/our child at U Empower of Maryland's ("UEOM's") The Food Project, located at 424 S. Pulaski Street, Baltimore, MD 21223, we accept the obligations imposed herein and waive certain rights as explained herein:
1. Myself/Our child has the following allergies or herein condition (such as diabetes) that may require medication (listed below)
Medications:
*
Please list any medications your child is currently on:
2.I/We will bring in a medical authorization form and directions provided by our child’s physician regarding the administration of medication for allergic reactions or other emergency situations arising from my/our child’s health condition.
3.I/We have left an emergency dose of the medications with The Food Project for use if my/our child suffers an allergic reaction, diabetic reaction, or other emergency related to the health conditions listed above while in the care or custody of The Food Project. I/We will update the medication left with The Food Project if/when my/our child’s medications change. I/We will also renew the medication if its consumption is time-critical or if it expires.
4.In the event that my/our child suffers a serious allergy attack, diabetic reaction or illness while in the care or custody of UEOM's The Food Project, I/we authorize The Food Project to administer medication orally or through the use of an injection, Epi-Pen or such other method as I/we have made available to The Food Project, or to take such other action as is reasonably necessary to remedy or abate the allergic reaction. I/We waive the right to any suit or complaint, claim, charge, demand or damages against UEOM's The Food Project and/or any employee, teacher, teacher staff member, agent, independent contractor, officer or director of the School arising from our efforts to abate or remedy an allergic reaction, diabetic reaction or emergency related to my/our child’s health condition as listed
Media Release
I, the undersigned, authorize the staff of U Empower of Maryland and affiliated departments and organizations to record, film and videotape my voice and image and to photograph my person.
I further authorize U Empower of Maryland to use, televise, and publish (in print, radio or on the Internet) such voice and image recording and photographs for any purpose which U Empower of Maryland deems suitable. I understand that U Empower of Maryland intends to advertise, market, and distribute the above-named production, and I hereby release any and all interest which I have or may hereafter acquire in any proceeds from such sale or distribution of said production. I agree that no representations have been made regarding the purpose or use of my voice or image except those set forth in this release.
In consideration of participation in the media production described herein, I do for myself, my heirs, executor, administrators, legal representative and assigns release and forever discharge the agent, and employees and all other persons connected with the named production from any and every claim, demand, action, in law or equity that may arise as a result of my participation in the production named in this release.
I further state that I have carefully read the terms of this release. I understand that I am signing a complete release and bar to any claim resulting from my participation in the production named in this release.
Text Area
